Hourglass-Like Constrictions of Peripheral Nerve in the Upper Extremity

Pan, Yuanjiang; Wang, Shufeng; Zheng, Dan-feng; Tian, Wen; Gao, Tian; Ho, Pak Cheong; Cheng, Hi-Shan; Zhong, Yan

doi:10.1227/neu.0000000000000350

Cited by 105 publications

(138 citation statements)

References 37 publications

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“…Edema due to inflammation may first give rise to nerve enlargement. Adhesions and local fixation of fascicles may also develop, leading to thinning and constriction of the fascicles/nerves . If the constriction increases, the likelihood of nerve torsion increases, as proposed by Lundborg .…”

Section: Discussionmentioning

confidence: 99%

“…Recently, Pan and colleagues studied a series of 42 patients with hourglass‐like constriction, of whom 41 had a neuralgic amyotrophy‐like presentation . Furthermore, in all cases with histological assessment, an inflammatory cell infiltration of CD8‐positive T lymphocytes was observed.…”

Section: Discussionmentioning

confidence: 99%

“…When available, histology showed inflammatory signs. The nerves were treated with neurolysis or resection and graft implantation, with generally good recovery . Interestingly, this type of nerve lesion and its possible causes have so far received little attention from the neurological community.…”

mentioning

confidence: 99%

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Ultrasonographic identification of nerve pathology in neuralgic amyotrophy: Enlargement, constriction, fascicular entwinement, and torsion

et al. 2015

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Objective: To characterize the ultrasonographic findings on nerves in neuralgic amyotrophy.Methods: Fourteen patients with neuralgic amyotrophy were examined using high resolution ultrasound.Results: Four types of abnormalities were found: 1. Focal or diffuse nerve / fascicle enlargement (57%), 2. incomplete nerve constriction (36%), 3. complete nerve constriction with torsion (50%) (hourglass-like appearance), and 4. fascicular entwinement (28%). Torsions were confirmed intraoperatively and occurred on the radial nerve in 85% of the patients. A significant correlation was found between no spontaneous recovery of nerve function and constriction / torsion / fascicular entwinement (p=0.007). Conclusion:Ultrasonographic nerve pathology in neuralgic amyotrophy varies in order of severity from nerve enlargement to constriction to nerve torsion, with treatment moving from conservative to surgical. We postulate that the constriction caused by inflammation is the precursor of torsion and that the development of nerve torsion is facilitated by rotational movements of limbs.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Ultrasonographic identification of nerve pathology in neuralgic amyotrophy: Enlargement, constriction, fascicular entwinement, and torsion

et al. 2015

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“…Recent data support another hypothesis about the interaction of biomechanical factors and inflammation. It has been postulated that rotational movements of the limbs can cause already inflamed nerves to become twisted, leading to neuralgic amyotrophy that shows typical ultrasound and intraoperative abnormalities appearing as hourglass constrictions and fascicular entwinement . Thus, biomechanical factors may contribute to nerve inflammation by causing wear‐and‐tear stress to the blood–nerve barrier as well as torsion of inflamed nerves, leading to additional damage.…”

Section: Pathophysiologymentioning

confidence: 99%

“…Severely affected nerve may show focal constrictions that likely reflect scarring due to Sunderland grade IV pathology caused by the inflammation, leading to the “string‐of‐beads” appearance in longitudinal scans (Fig. ) …”

Section: Imaging Studiesmentioning

confidence: 99%

Neuralgic amyotrophy: An update on diagnosis, pathophysiology, and treatment

Groothuis²,

2016

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In this review we provide a current overview of the clinical features, pathophysiology, epidemiology, and diagnostic and therapeutic strategies in neuralgic amyotrophy (NA). The disorder has several phenotypic variations, with a classic form in 70% of the patients. It is not rare, with an incidence of 1 per 1,000 individuals, but it is still often missed. Recurrences are common, yet the proposed multifactorial etiology, which includes genetic, biomechanical, and immunologic factors, limits our capacity to predict or prevent them. NA is a clinical diagnosis, and ancillary studies serve to exclude infectious or malignant causes or to assess a differential diagnosis. If patients are seen early and are still in pain, a short trial of high-dose oral corticosteroids is advised, and adequate analgesia may require opioids and non-steroidal anti-inflammatory drugs. Persistent complaints are common, and a multidisciplinary rehabilitation approach focusing on scapular coordination, energy distribution strategies, and self-management is indicated.

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Variation of surgical anatomy of the thoracic portion of the long thoracic nerve

Ormsby

Hawkes

2021

Clinical Anatomy

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Decompression of the long thoracic nerve (LTN) is a potentially beneficial procedure for selected patients with LTN palsy. The aim of this work is to describe the surgical anatomy of the thoracic part of the LTN and highlight its variations. A retrospective review of patients undergoing exploration of the LTN was performed. Preoperatively, all patients had serratus anterior dysfunction and underwent electromyographic (EMG) assessment. All patients had an initial trial of nonoperative management. The surgical procedures were undertaken by the senior author. The anatomy of the LTN and the associated vasculature was recorded in patient records, and with digital photography. Forty‐five patients underwent LTN exploration. Two patients with iatrogenic injury were excluded, leaving 43 patients for analysis. Mean age was 36 years. Sixty‐seven percent of cases involved the dominant side. Trauma was the commonest cause, followed by neuralgic amyotrophy. Four patients had typical features of serratus anterior dysfunction but with normal EMG studies. Two distinct patterns of LTN anatomy were noted. In 79% of cases, a single major nerve trunk coursing along serratus anterior was observed and classified as a type I LTN. In 21% of cases, two equal major branches of the nerve were identified, which was classified as a type II LTN. Approximately one in five patients may have two major branches of the LTN. This is of clinical relevance to those who undertake any thoracic procedures, as well as those who are considering exploration of the LTN.

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Hourglass-Like Constrictions of Peripheral Nerve in the Upper Extremity

Abstract: The clinical presentation of patients with hourglass-like constrictions in their nerves is similar to that of patients with neuralgic amyotrophy. Histochemical analysis suggests that the pathogenesis may be immunological in origin. The role of surgery in this condition is uncertain.

Cited by 105 publications

References 37 publications

Ultrasonographic identification of nerve pathology in neuralgic amyotrophy: Enlargement, constriction, fascicular entwinement, and torsion

Ultrasonographic identification of nerve pathology in neuralgic amyotrophy: Enlargement, constriction, fascicular entwinement, and torsion

Neuralgic amyotrophy: An update on diagnosis, pathophysiology, and treatment

Variation of surgical anatomy of the thoracic portion of the long thoracic nerve

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